This past week, most of the various national news media carried the story of an 87 year old woman in an independent living facility in California. She collapsed during lunch, and--in keeping with the policy in place at the facility--staff called 911 for an emergency medical transport to come. The 911 operator asked about the woman's immediate state--was she breathing? And when the staff person said that the woman was breathing only faintly, the 911 operator sternly instructed the staff person--you have to start CPR right now.
When the staff person, identified as a nurse, demurred, the 911 operator became very insistent and said--she might die. And, therewith, the focus of the story became clear. The only fault seemed to be the refusal of the nurse to begin CPR.
But there are other questions that should have been asked. Did the 87 year old woman have an advance directive? Did she want CPR to be given in the event that she suffered cardiac arrest or some other catastrophic health event? What did her family want for her treatment? How effective is CPR? What were her chances of survival even with CPR? Perhaps predictably, none of those questions was asked--the initial news coverage seemingly tripped over itself trying to make the story as negative and sensational as possible. I must, however, give credit to NBC which did begin to raise the questions.
We have been so accustomed to seeing CPR performed as part of a dramatic scene in a television drama that we most likely assume it always works. But does it? The short answer is no.
One website indicates that CPR is rarely effective:
- 2% to 30% effectiveness when administered outside of the hospital
- 6% to 15% for hospitalized patients
- Less than 5% for elderly victims with multiple medical problems
Recently, my husband and I updated our wills, which--this time--included advance directives. We want our preferences to be known to family and health professionals. There comes a time when enough is enough.
This is not an easy subject to broach. And the question goes beyond end of life care--it should even be raised in smaller ways. Part of the reason that Medicare consumes the amount of money it does is because so many procedures are paid for. True, they are paid for at Medicare's rate--but, to my knowledge, there is no information for patients that says "you don't have to have every procedure a doctor recommends."
I am currently helping my elderly father (93) and my step-mother (80) make various decisions. I am struck by the number of times that a medical provider simply schedules the next appointment for 6 months. True, these appointments are well-care appointments, and--generally--that is the best approach to medicine. But when I picked my step-mother up from her recent dermatology appointment, the nurse scheduled her for a 6-month checkup. So I pushed back a bit--why 6 months? The nurse said--well, there' s a history of skin cancer. So I asked my step-mother--how long ago? She couldn't quite recall, but said nothing recently. I have had multiple basal cell skin cancers--and I go for checkups once a year.
I suggested to my father and step-mother that they can decline to schedule appointments if they feel they are unnecessary. To my thinking, this is especially true for simple skin care--skin cancers (other than melanoma) takes YEARS, even decades, to develop. And is that a serious concern for someone in his or her 80s or 90s? Please understand, I also ask myself the question--at my age.
So, it all comes back to the question of when is enough enough? I think part of American obsession with youth, with seeming never-ending life, feeds the tendency to think we must always intervene--always give CPR. But, part of the human bargain is this: we are born AND we die.
Sometimes enough is enough.